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RCP 180 Exam 1

Causes of metabolic alkalosis gastrointestinal tract loss of hydrogen ions, renal loss of hydrogen ions, intracellular shift of hydrogen ions, contraction of blood volume, and administration of a base.
Causes of metabolic acidosis ingestion of acids, increased fixed acid production, or decreased renal excretion of acid
Causes of respiratory acidosis increased work of breathing resulting in decreased ventilation, decreased ventilatory drive, and neurologic or neuromuscular disease resulting in decreased ventilation
Causes of respiratory alkalosis hypoxemia, pain and anxiety, fever, early sepsis, but receptor stimulation, and in compensation for metabolic acidosis.
Arterial blood gas (ABG) Test to measure degree of hypoxemia as well as metabolic status
Causes of hypoxemic respiratory failure Atelectasis, pneumonia, and pulmonary edema
Causes of acute respiratory failure acute asthma, exacerbation of COPD, pneumonia, ARDS, shock, trauma, sepsis, cardiac or cardiovascular disease, neurologic or neuromuscular disease
Causes of respiratory failure Decreased ventilation-to-perfusion ratio, pulmonary shunt, diffusion problems, hypoventilation, low blood O2 content, increased pulmonary dead space, acute ventilatory failure, chronic ventilatory failure
Enteral a tube into the stomach or small bowel
Parenteral done intravenously
APACHE useful in predicting mortality and length of stay in ICU patients (4 versions)
SAPS useful in predicting mortality in ICU patients (3 versions)
SOFA predicts ICU mortality based on the level of dysfunction of 6 organ systems; useful to assess the level of organ dysfunction and identify patients at risk of dying of sepsis
ICU nutrition and patients with respiratory failure. What they may be experiencing They may be experiencing a catabolic stress state, systemic inflammatory response, infection, multisystem organ failure, and increased morbidity and mortality associated with critical illness
Total cycle time equation Total cycle time = Inspiratory time + Expiratory time
Inspiratory time occurs when inspiratory gas flow moves from zero to peak and back to zero at the end of inspiration
Expiratory time begins at the end of inspiration with airflow at zero and continues until the start of the next inspiratory cycle
Bird Mark 7 time or patient triggered to inspiration and pressure cycled to expiration
Bennett PR-2 time or patient triggered to inspiration and flow cycled to expiration
Benefits of patient and time triggered ventilators that were introduced in the 1960’s Less space requirements, patient access, and the ability to set a precise tidal volume and backup respiratory rate
How is a Plateau pressure measured? During volume control (VC) plateau pressure is measured during an inspiratory hold maneuver, typically one second or less in duration
What is extrinsic PEEP? PEEP set intentionally to improve lung volumes and oxygenation
When would an oro-mask or nasal mask be provided? Noninvasive CPAP
Highest pressure attained on inspiration is called what? Peak inspiratory pressure (PIP)
Be able to calculate alveolar ventilation per minute (not minute ventilation) Tidal volume – dead space x respiratory rate
What is deadspace volume? The volume of inspired gas that fills the conducting zone of the lung and any unperfused alveoli
Input power on a ventilator The power source used by the ventilator to perform the required work; may be electric or pneumatic
Physiologic PEEP a small amount of PEEP (3 to 5 cm H2O) used for most patients to prevent expiratory alveolar collapse
Best PEEP the PEEP that maximizes oxygen delivery to the tissues
Auto PEEP unintended PEEP usually caused by airflow obstruction and/or inadequate expiratory time. It is also known as air trapping or dynamic hyperinflation and is more common in patients with obstructive lung disease (intrinsic PEEP or occult PEEP)
Continuous positive airway pressure (CPAP) Spontaneous breathing at an elevated pressure line
What is CMV (Continuous mandatory ventilation)? The control variable can be volume or pressure, every breath is mandatory. The patient may trigger inspiration, but every breath is machine cycled to expiration. If no spontaneous breaths occur the ventilator delivers a time-triggered breath at the set RR
VC (volume control) a constant tidal volume is delivered; inspiratory pressure varies with changes in the patient’s compliance and resistance.
PC (pressure control) a constant inspiratory pressure is delivered; tidal volume varies with changes in the patient’s compliance, resistance, and inspiratory effort
Industry standad for Vt 6-8 ml/kg/IBW
The BEST way to measure ventilation is the measurement of PaCO2
SIMV (Synchronized intermittent mandatory ventilation) allows patients to breathe spontaneously between mandatory breaths and the machine breaths are “synchronized” to the end of the patient’s exhalation
Trigger variables time and patient effort
Cycle variables volume, pressure, flow, and time
VC-IMV Volume control- intermittent mandatory ventilation Control variable: volume, During mandatory breaths volume delivery remains constant
PC-IMV Pressure control- intermittent mandatory ventilation Control variable: Pressure IMV indicates that the patient may breathe spontaneously in between mandatory breaths
VC-CMV Volume control- continuous mandatory ventilation Control variable: volume Both volume and flow are preset prior to inspiration and volume delivery is not affected by changes in lung compliance or airway resistance
PC-CMV Pressure control- continuous mandatory ventilation Control variable: pressure Inspiratory pressure is preset as either a constant value or proportional to the patient’s inspiratory effort. Inspiration is pressure limited and time cycled.
ASV (adaptive support ventilation) closed-loop, automated ventilation that combines pressure support & control. The vent adjusts the RR & inspiratory pressure based on mechanics for a target V̇E & prescribed level of pt WOB; the vent will adjust to change in mechanics & pt effort.
High-frequency positive pressure ventilation (HFPPV) generally uses tidal volumes in the range of 100 to 200 mL, with respiratory rates of 60 to 120 breaths/min, which can be accomplished using some conventional positive pressure ventilators
High-frequency jet ventilation (HFJV) HFJV tidal volumes can range from 3.5 to 4.5 mL/kg IBW with rates in the range of 100 to 200 breaths/min
High-frequency percussive ventilation (HFPV) HFPV combines high-frequency oscillatory pulses (200-900 bpm) & small tidal volumes with pressure-control ventilation May improve oxygenation & ventilation with reduced risk of barotrauma & hemodynamic compromise. Can also be useful in secretion clearance
High-frequency oscillatory ventilation (HFOV) Uses very small Vt (50-250 mL) and very high frequencies in the range of 180-900 breaths/min. HFOV is an active form of high-frequency ventilation as a vibrating diaphragm will create both a positive (inspiration) and negative (exhalation) wave.
PRVC varies pressure breath to breath to achieve a set _____________ Tidal volume
APRV can be described as ________ Airway pressure release ventilation- another mode used for spontaneously breathing patients. Provides two levels of CPAP that are time triggered and time cycled.
What is PAV Proportional Assist Ventilation (ventilator mode); a dual CPAP mode of ventilation
Patient Care Zone includes the patient rooms where the direct patient care is provided. Rooms should have doorways that allow for the fast and unobstructed movement to patients, beds, staff, and equipment.
Unit support zone the areas within the ICU where administrative & staff support functions occur. This area may include offices and conference spaces and often provide a location for change of shift reports. A staff soiled utility room may be included in this area
Clinical support zone in the ICU includes staff work areas, centralized monitoring stations, and workspace for order entry and medical record documentation and review.
Family support zone refers to those areas in or near the ICU designated to support families and visitors. This may include a family and visitors lounge, consultation rooms, meditation spaces, and other facilities for families and visitors
What are respiratory care plans? in the ICU may focus on improving oxygenation, ensuring adequate ventilation, providing cardiorespiratory support and monitoring the patient’s condition.
Monitoring Procedures In the ICU include respiratory, cardiac and hemodynamic monitoring
What is a thoracentesis indicated for? Removal of pleural fluid for both diagnostic and therapeutic purposes; for pleural effusion
respiratory failure the inability of the heart and lungs to maintain adequate tissue oxygenation and/or carbon dioxide removal
Hypoxemic respiratory failure (aka lung failure) is a problem with oxygenation
hypercapnic ventilatory failure (aka pump failure) is a problem with ventilation resulting in an abnormal increase in PaCO2
Acute Ventilatory Failure a sudden increase in PaCO2 with a corresponding decrease in pH.
Chronically Ventilatory failure when ventilatory failure is likely to occur in the immediate future.
Acute on chronic ventilatory failure- a chronically elevated PaCO2 with a normal or near-normal pH due to metabolic compensation (although complete compensation generally does not occur)
Impending ventilatory failure a chronically elevated PaCO2 followed by an acute increase in PaCO2 and a corresponding decrease in pH
Altitude hypoxia is defined by _______ reduced barometric pressure at altitude
Conditions that can lead to an increased capillary shunt ARDS, atelectasis, complete airway obstruction, consolidate pneumonia, large pneumothorax, and pulmonary edema
• Problems with the conducting airways which may impair oxygenation and/or ventilation include _______ airway obstruction, increased secretions, airway mucosal edema, and bronchospasm
HAPE ( high altitude Pulmonary edema)- life threatening medical emergency, occurs at higher elevations (>10,000 feet) & may be more likely in pts with pulmonary hypertension or left-to-right cardiac shunts.
HACE (High altitude cerebral edema) life threatening, associated with higher elevations (>10,000 feet), although may occur at lower altitudes (e.g., 8,000 feet)
Symptoms for HACE and HAPE include headache, loss of appetite, nausea, vomiting, sleep disturbance, fatigue and exertional dyspnea
Issues patients with severe anemia may experience profound hypoxia without cyanosis
Complications with sickle cell disease Acute chest syndrome associated with chest pain, hypoxemia, and pulmonary infiltrates on imaging
Anemic hypoxia occurs when the oxygen carrying ability of the blood decreases
Hypoxic patients who are under ventilating typically respond well to what? The administration of low to moderate concentrations of oxygen
Patients with a shunt respond well to what? Moderate to high concentrations of oxygen, PEEP, CPAP and/or mechanical ventilatory support
Oxygen delivery to the tissues can be calculated by multiplying: DO2 = CaO2 x Qt CaO2: arterial oxygen content (mL O2/100mL blood) Qt: cardiac output (mL/min)
How do we treat carbon monoxide poisoning administration of high concentrations of oxygen and in severe cases hyperbaric oxygen administration may be indicated
Causes of carbon monoxide poisoning exposure to improperly functioning heating systems, exhaust from motor vehicles or gas powered generators in poorly ventilated spaces, and inhalation of smoke from fires
Causes of secondary polycythemia Chronic hypoxemia, living at high altitude, or chronic exposure to carbon monoxide
Normal tissue oxygen delivery is about ______ per minute 1000 mL/min
Clinical manifestations of cyanide poisoning Headache, anxiety, confusion, vertigo, coma, seizures, vomiting, abdominal pain, and renal failure
Cardiogenic shock caused by low cardiac output
Hypovolemic shock caused by inadequate intravascular volume due to blood or fluid loss
Obstructive shock caused by obstruction of blood flow from the heart or major vessels
Distributive shock caused by inappropriate peripheral vasodilation results in decreased systemic vascular resistance and low blood pressure
Septic shock caused by an overwhelming infection and results in decreased systemic vascular resistance
Neurogenic shock caused by head trauma, brain injury and cervical or thoracic spinal cord injury, which may result in a loss of sympathetic stimulation, vasodilation, and a decrease in peripheral vascular resistance
Anaphylactic shock is due to an allergic reaction to a drug or other substance
Causes of left shift of the dissociation curve caused by severe alkalosis, marked hyperventilation, hypothermia, or carbon monoxide poisoning, hypocapnia, decreased 2,3-DPG levels
Causes of right shift of the dissociation curve caused by acidosis, hyperthermia (fever), hypercarbia, increased 2,3-DPG levels and hypoventilation
Circulatory hypoxia is also known as Stagnant hypoxia
Causes of reduced cardiac output Ischemic heart disease, myocardial infarction, cardiac arrythmias, congestive heart failure, hypovolemia, and late septic shock
Causes of increased alveolar deadspace Emphysema or pulmonary embolus
Tests used to assess the adequacy of spontaneous ventilation Bedside spirometry, measurement of vital capacity, maximum voluntary ventilation, maximum inspiratory pressure, and calculation of the rapid shallow breathing index
ventilation The bulk movement of air into and out of the lungs
How to treat cyanide poisoning Administration of cyanide antidotes, high concentrations of oxygen therapy, intubation to secure the airway, and mechanical ventilatory support
Decreased mixed venous oxygen levels can be caused by: Arterial hypoxemia, decreased cardiac output, increased oxygen consumption
Causes of cardiac arrest Severe hypoxia, shock, trauma, myocardial infarction, failure to institute mechanical ventilatory support in the presence of extended periods of apnea, myocardial ischemia, cardiac arrythmias, severe hypotension
Indications for mechanical ventilation apnea, acute ventilatory failure, impending ventilatory failure, and severe oxygenation problems
Contraindications for mechanical ventilation Pneumothorax without chest tubes, absence of clear indications, rapid resolution of apnea or ventilatory failure, futility of intervention, or mechanical ventilation is against the patient’s wishes
Complications for mechanical ventilation barotrauma, ventilator associated lung injury, airway injury, infection, ventilator associated pneumonia, pulmonary embolus, hypotension, and stress ulcers (gastrointestinal bleeding
Goals of mechanical ventilation Providing adequate alveolar ventilation and oxygenation, restoring and maintaining acid-base homeostasis, reducing the WOB, ensuring pt safety and comfort, minimizing harmful side effects and complications, and promoting liberation of the pt from the vent
Hazards and Complications of mechanical ventilation Barotrauma, airway injury, infection, VAP, pulmonary embolus, gastrointestinal bleeding, and ventilatory muscle atrophy and dysfunction
What can cause ventilatory muscle paralysis Neuromuscular blocking agents (block nerve transmission at the myoneural junction)
• What is inversely proportional to alveolar ventilation and directly proportional to carbon dioxide production (VC02)? PaCO2
• Define refractory hypoxemia, and what are patients especially needing to help resolve it? Refractory hypoxemia is an oxygenation problem which does not respond to conventional oxygen therapy Patients may require the use of PEEP or CPAP to resolve it
• Define critical care and the patient that is needing critical care Critical care refers to the care and management of critically ill patients who require sophisticated support and constant monitoring Critically ill patients are at high risk of life-threatening health problems; patients with acute and chronic respiratory
Respiratory care A subject area within medical practice that encompasses diagnostic, therapeutic, and support services involved in the care of patients with disorders that affect the respiratory system.
Long term care care provided to patients with serious medical conditions requiring an extended hospital stay, but no longer requiring intensive care or extensive diagnostic procedures.
emergency department Trauma center
ICU - A hospital unit that provides continual care to severely ill patients who need close observation and rapid response to changes in their condition.
Step down unit Secondary care facilities in a hospital intended for patients who have been in ICU who continue to need long-term acute care but no longer need intensive care.
CCU - The traditional coronary care unit tends to focus on to providing care to patients following acute myocardial infarction (MI), patients with unstable angina, and those with other serious cardiac arrhythmias.
SICU An intensive care unit that primarily serves critically ill postoperative patients and is staffed and managed by surgeons and anesthesiologists with training and specialization in critical care.
NICU The NICU provides care for critically ill newborns. Respiratory care provided may include provision of a neutral thermal environment, monitoring, surfactant therapy, oxygen therapy, (CPAP), & vent support ECMO & inhaled nitric oxide therapy
PICU The PICU focuses on the care of critically ill children, typically ranging in age from infants-teenagers. PICU services: basic respiratory care, pt assessment & monitoring, providing vent support, ECMO, HFV, & inhaled nitric oxide therapy
Neurologic Intensive Care Unit (Neuro ICU). The Neuro-ICU focuses on the care of patients with critical, life-threatening neurological disorders such as stroke, cerebral aneurysm, head trauma, traumatic brain injury, intracranial or subarachnoid hemorrhage, encephalitis, and others
Cardiovascular Intensive Care Unit (CVICU). The types of patients seen in the CVICU vary, depending on the hospital. In hospitals with separate CCU services, the CVICU tends to focus on postoperative care following cardiothoracic or vascular surgery.
ventilator induced diaphragmatic dysfunction can develop within hours and worsens with the duration of mechanical ventilation. This may be related to increased oxidative stress on the diaphragm. Direct measures of diaphragmatic function have been elusive
different types of inspiratory flow waveforms include square, ascending, descending, and sinusoidal
What mode uses EMG signal? NAVA Neurally adjusted ventilatory assist
What type of patient on the vent would benefit from a cerebral vasoconstrictor Decreased PCO2 is a cerebral vasoconstrictor while increased PCO2 is a cerebral vasodilator. Thus, hyperventilation can be used to lower ICP, and this has been suggested in the past to treat patients with severe head trauma and/or cerebral edema
Sleep fragmentation and sleep disruption can have a negative impact on, what? When sleep fragmentation is displaced by sleep loss, daytime sleepiness is the result, which may delay weaning from mechanical ventilation.
The amount of air that can be moved into and out of the lungs by the ventilatory pump is the ventilatory ________ Capacity
ventilatory demand Refers to the volume of ventilation required to achieve adequate oxygenation and carbon dioxide removal
What determines alveolar ventilation? tidal volume minus dead space times respiratory rate
Causes of reduced ventilatory capacity Diaphragmatic fatigue due to increased work of breathing
Created by: K.Moskowitz
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